315920153-5-13-2026-59-AS-LMUZ-DUANDD-20260521102209

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315920153
Report Date: 05/13/2026
Date Signed: 05/13/2026 12:29:06 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/14/2026 and conducted by Evaluator Cassandra Mikkelson

COMPLAINT CONTROL NUMBER: 59-AS-20260414151338

FACILITY NAME:	JANNAT ASSISTED LIVING		FACILITY NUMBER:	315920153
ADMINISTRATOR:	KUMARI ANJANA		FACILITY TYPE:	740
ADDRESS:	6882 BRANDY CIRCLE		TELEPHONE:	(669) 337-5574
CITY:	GRANITE BAY	STATE: CA	ZIP CODE:	95746
CAPACITY:	6	CENSUS: 5	DATE:	05/13/2026
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Anjana Kumari		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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9

Staff mismanages residents' medication records.

INVESTIGATION FINDINGS:

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Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Anjana Kumari to deliver findings for the above complaint allegation.

During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

*** Report continued on 9099-C***

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 59-AS-20260414151338

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: JANNAT ASSISTED LIVING	FACILITY NUMBER: 315920153
	VISIT DATE: 05/13/2026

NARRATIVE

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Staff mismanages residents' medication records.

Records reviewed indicated that medication lists from the physician’s do not completely match the medications at the facility for each resident. Centrally stored medication forms are being utilized but not fully completed accurately based on medication list from physicians. Observations indicated that medication is not being kept in it’s original container but being placed in a weekly administration container for each resident in care. Observations also indicated that there are medications stored that are expired or not on the current medication list for each resident. Therefore, the allegation staff mismanages residents’ medication records is substantiated.

Based on the information obtained for the allegation above, the allegation are SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Exit interview conducted with Executive Director and a copy of the report and appeal rights was provided.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 59-AS-20260414151338

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: JANNAT ASSISTED LIVING	FACILITY NUMBER: 315920153
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/13/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/27/2026 Section Cited CCR 87465(h)(6)	1 2 3 4 5 6 7	87465(h)(6)--- (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:	1 2 3 4 5 6 7	Administrator will conduct a medication audit for each resident to ensure all medicaiton lists, Centrally Stored Medication Records and administration records match and send information to LPA by POC due date. Administrator will also complete TSP referral.
	8 9 10 11 12 13 14	This was not met by evidenced by: R1 and R4 medications, Centrally Stored Medication Record and administration records reviewed and did not match medications on file.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/14/2026 and conducted by Evaluator Cassandra Mikkelson

COMPLAINT CONTROL NUMBER: 59-AS-20260414151338

FACILITY NAME:	JANNAT ASSISTED LIVING		FACILITY NUMBER:	315920153
ADMINISTRATOR:	KUMARI ANJANA		FACILITY TYPE:	740
ADDRESS:	6882 BRANDY CIRCLE		TELEPHONE:	(669) 337-5574
CITY:	GRANITE BAY	STATE: CA	ZIP CODE:	95746
CAPACITY:	6	CENSUS: 5	DATE:	05/13/2026
		UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Anjana Kumari		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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9

Staff do not provide a comfortable environment for the residents.
Staff do not provide residents with adequate meal service.

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 59-AS-20260414151338

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: JANNAT ASSISTED LIVING	FACILITY NUMBER: 315920153
	VISIT DATE: 05/13/2026

NARRATIVE

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Staff do not provide a comfortable environment for the residents.

Interviews conducted with residents indicated that they feel safe within the home and that staff are helpful. Interviews with administrator and staff indicated that there are only staff and visitors of residents who are in the home. Staff and residents have not witnessed anyone without clearance in the facility at any time. Residents have visitors on a daily basis but have not witnessed anyone uninvited within the home. Therefore, the allegation staff do not provide a comfortable environment for the residents is unfounded.

Staff do not provide residents with adequate meal service.

Records reviewed indicated that Residents R3 and R5 are on a modified diet according to their physician’s report. Interviews conducted with residents indicated that the food is okay and there is no concerns about the menu or variety of food offered. Interviews with administrator and staff indicated that menus are discussed with residents. Snacks and meals are provided and are a variety based on requests from residents in care. Modified diets are followed for residents based on their LIC602. Therefore, the allegation staff do not provide residents with adequate meal service is unfounded.

Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 5